COVID-19 Patient Waitlist Form

Pre-Vaccination Checklist for FIRST DOSE of COVID-19 Vaccine

For vaccine recipients: The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
Instructions

Please fill in the fields below. Holmes Pharmacy staff will add your information to our COVID-19 Vaccine waitlist. Missing or inadequate information may result in a longer wait time. Duplicate information will not increase availability. We will contact you to schedule appointments.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code/County
Email *
example@example.com
Date of Birth: MMDDYYYY *
MMDDYYYY
Phone Number *
Please enter a valid phone number.
Gender: Please select. *
Required by Georgia Registry of Immunization
Please list the state where you were born. *
Required by Georgia Registry of Immunization
Ethnicity: Please choose from the following options. *
Required by Georgia Registry of Immunization
Race: Please choose from the following options. *
Required by Georgia Registry of Immunization
Which location would you like to send your information to? *
Choose a location from the drop down menu.
Mother's First name & MAIDEN last name *

First Name Last Name
Which vaccine would you like to receive? *
Choose one of the drop down options
Please choose which category best describes you. See descriptions above if unsure.

65+years old & Caregiver Educators & Staff Parents of children with complex medical conditions Adults with intellectual/developmental disabilities & their caregivers Law Enforcement, First Responder, Fire Personnel 55+ years old Healthcare worker Long Term Care Facility Staff or Resident Other
Please describe, in detail, which phase applies to you. List each condition or diagnosis below. *
Ex: 55+ with diabetes; Disabled child with Autism; Educator; Law Enforcement,etc.. PLEASE BE SPECIFIC.
Based on selection above, please list all conditions or diagnosis that apply to you. *
Ex: 55+ with diabetes; Disabled child with Autism; Educator; Law Enforcement,etc.. PLEASE BE SPECIFIC.
Do you have insurance? Choose from dropdown options. *
For those with Medicare, Please choose A&B (Red, White, & Blue card)
Social Security Number *
Providing this information will confirm/search your insurance coverage.
Please provide any Insurance information available (Member ID #, BIN #, Group #) *
Include as much information as possible. The lack of information will delay response time for appt.
Rx BIN # *
If Medicare A & B (Red, White, & Blue card), no BIN # is needed. Please type "NONE"
RX Group # *
Member ID # *
1. Are you feeling sick today? (fever, cough, runny nose, or body aches?) *

NO YES- Specify_________________________________________________________________
2. Have you ever received a dose of COVID-19vaccine? • If yes, which vaccine product? Pfizer/ Moderna /Another product • When? List date of first vaccine. • If not given at Holmes Pharmacy, where was first dose given? *
Answer YES or NO. Specify product & date received, & where dose was given.
3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital? • Was the severe allergic reaction after receiving a COVID-19 vaccine? • Was the severe allergic reaction after receiving another vaccine or another injectable medication? *
4. Have you received passive antibody therapy (monoclonal antibodies or convalescent-serum) as treatment for COVID-19? *
5. Have you received another vaccine in the last 14 days? *
6. Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? If yes, when? *
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? If yes, specify. *
8. Do you have a bleeding disorder or are you taking a blood thinner? *
9. Are you pregnant or breastfeeding? *
Consent: I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Holmes Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Holmes Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. * I understand that this is not registering me for an appointment. This form serves the purpose of letting Holmes Pharmacy know I am interested in getting a vaccine, and it provides the necessary information for Holmes Pharmacy to contact me when a vaccine is available to me based on the current phases and availability. *

Clear
If signing up a MINOR (under 18) for PFIZER vaccine, Enter PARENTS NAME.

First Name Last Name
Date *

Month Day Year
Date
Appointment
Should be Empty:

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Pre-Vaccination Checklist for FIRST DOSE of COVID-19 Vaccine

Instructions